Evaluation of Nail Abnormalities
AMBER S. TULLY, MD, Cleveland Clinic, Strongsville, Ohio
KATHRYN P. TRAYES, MD, and JAMES S. STUDDIFORD, MD, Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Knowledge of the anatomy and function of the nail apparatus is essential when performing the physical examination. Inspection may reveal localized nail abnormalities that should be treated, or may provide clues to an underlying systemic disease that requires further workup. Excessive keratinaceous material under the nail bed in a distal
and lateral distribution should prompt an evaluation for onychomycosis. Onychomycosis may be diagnosed through
potassium hydroxide examination of scrapings. If potassium hydroxide testing is negative for the condition, a nail
culture or nail plate biopsy should be performed. A proliferating, erythematous, disruptive mass in the nail bed
should be carefully evaluated for underlying squamous cell carcinoma. Longitudinal melanonychia (vertical nail
bands) must be differentiated from subungual melanomas, which account for 50 percent of melanomas in persons with dark skin. Dystrophic longitudinal ridges and subungual
hematomas are local conditions caused by trauma. Edema and erythema of the proximal and lateral nail folds are hallmark features of
acute and chronic paronychia. Clubbing may suggest an underlying
disease such as cirrhosis, chronic obstructive pulmonary disease, or
celiac sprue. Koilonychia (spoon nail) is commonly associated with
iron deficiency anemia. Splinter hemorrhages may herald endocarditis, although other causes should be considered. Beau lines can
mark the onset of a severe underlying illness, whereas Muehrcke
lines are associated with hypoalbuminemia. A pincer nail deformity
is inherited or acquired and can be associated with beta-blocker use,
psoriasis, onychomycosis, tumors of the nail apparatus, systemic
lupus erythematosus, Kawasaki disease, and malignancy. (Am Fam
Physician. 2012;85(8):779-787. Copyright © 2012 American Academy of Family Physicians.)
A
thorough inspection of the finger­
nails and toenails during the
physical examination may reveal
localized nail abnormalities that
should be treated, or may provide clues to an
underlying systemic disease requiring fur­
ther workup. Tables 11-9 and 21,10-15 list nail
abnormalities with localized and systemic
etiologies.
Figure 1 illustrates normal nail anatomy.
The nail matrix, located at the proximal nail
bed, creates the hard keratinous nail plate.
The distal nail matrix is responsible for lay­
ing down the deeper layers of the nail plate,
whereas the proximal nail matrix creates the
superficial layers. Therefore, the nail prob­
lem will reflect the location of nail matrix
disruption. Disruption of the proximal
nail matrix may lead to superficial nail pit­
ting, whereas interruption of the distal nail
matrix may cause deeper nail ridging. The
nail is bound to the underlying skin proxi­
mally by the eponychium, distally by the
anterior ligament and the distal nail fold,
and on the sides by the lateral nail folds. Dis­
ruption in the attachment of the nail plate to
the underlying skin may predispose patients
to localized infections. Because nails grow
slowly (six months to replace the fingernail,
and 12 to 18 months to replace the toenail), a
nail plate abnormality may reflect an illness
that occurred several months prior.16
Local Nail Abnormalities
DYSTROPHIC NAILS (SELF-INDUCED)
Dystrophic nails (Figure 2) can be caused
by repeated manipulation of the nail plate
(e.g., manicures/pedicures, biting, rubbing).
Repeated longitudinal scraping or manipu­
lation can lead to changes of the cuticle and
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Nail Abnormalities
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Oral terbinafine (Lamisil) has been shown to be an effective long-term therapy for
onychomycosis caused by fungal infections. Oral itraconazole (Sporanox) may be more
effective for yeast or nondermatophytic mold infections.
Treatment of squamous cell carcinoma of the nail includes Mohs surgery or amputation.
If no abscess is present, oral antibiotics should be used to treat severe acute paronychia, with
consideration for methicillin-resistant Staphylococcus aureus coverage in high-prevalence
areas and anaerobic bacteria coverage if exposure to oral flora is suspected.
Surgical treatment modalities for pincer nail include nail bed cutting with or without splinting.
Evidence
rating
References
A
2, 3, 21
C
C
8
5-7, 23
C
26
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
Table 1. Nail Abnormalities Associated with Localized Conditions
Nail finding
Etiologies
Treatment
Dystrophic nails (Figure 2)
Repeated nail manipulation (manicures/pedicures,
biting, rubbing)
Stop manipulation
Leukonychia (Figure 3)
Normal variant
No treatment
Longitudinal melanonychia
(vertical nail bands;
Figure 4)
Normal variant
Subungual melanoma
No treatment if idiopathic, treatment of
underlying condition, biopsy if concern
for melanoma1
Onychomycosis (Figure 5)
Infection with yeast, fungus, or nondermatophytic
mold
Oral terbinafine (Lamisil),2 itraconazole
(Sporanox),3 or fluconazole (Diflucan) 4
Acute (Figure 6A)
Aerobic bacteria: Staphylococcus aureus,
Streptococcus pyogenes
Anaerobic bacteria: Bacteroides, Fusobacterium
nucleatum, gram-positive cocci5
Warm soaks, topical antibiotic, topical
corticosteroid, surgical drainage (if
abscess is present) 6
Chronic (Figure 6B)
Immunosuppression (e.g., human immunodeficiency
virus infection, diabetes mellitus) increases the risk
Squamous cell carcinoma
Malignant melanoma
Avoidance of irritant, treatment of
underlying illness, broad-spectrum topical
antifungals for superinfection, biopsy if
concern for malignancy 7
With pseudomonal
superinfection
(Figure 6C)
Repeated minor trauma in a chronically wet
environment; higher risk in bartenders,
dishwashers, and habitual nail-biters
Topical neomycin
Squamous cell carcinoma
(Figure 7)
Commonly mistaken for verrucous lesion,
onychomycosis, or amelanotic melanoma
Mohs surgery, possible amputation of
affected digit 8
Subungual hematoma
(Figure 8)
Trauma
Nail puncture to relieve pressure, possible
nail removal 9
Paronychia
Information from references 1 through 9.
the nail plate, such as the cuticle becoming
pushed back, splitting or indentation in the
midline of the nail (median nail dystrophy),
or inflammation or thickening of the proxi­
mal nail fold.
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LEUKONYCHIA
Leukonychia (Figure 3) is an abnormal kera­
tinization of the underlying nail matrix
resulting in a white discoloration of the nail
plate.17 These nonuniform white lines may
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Table 2. Nail Abnormalities Associated with Systemic Conditions
Nail finding
Etiologies
Beau lines (Figure 9)
Clubbing (Figure 10)
Severe illness, Reynaud disease, pemphigus, chemotherapy, high fever1
Unilateral: hemiplegia, vascular disorders
Bilateral: empyema, cystic fibrosis, pulmonary fibrosis, celiac sprue,
bronchiectasis, cardiac disease, cirrhosis, chronic obstructive pulmonary
disease, inflammatory bowel disease1
Iron deficiency with or without anemia, hemochromatosis, trauma, Raynaud
disease, hypothyroidism, systemic lupus erythematosus, occupational
exposure to petroleum-based solvents, nail-patella syndrome10
Arsenic poisoning,1 other heavy metal poisoning, renal failure11
Hypoalbuminemia, nephrotic syndrome, liver disease, malnutrition12
Koilonychia (spoon
nail; Figure 11)
Mees lines
Muehrcke lines
(Figure 12)
Pincer nail (Figure 13)
Splinter hemorrhage
(Figure 14)
NOTE: Treatment
Systemic lupus erythematosus, psoriasis, onychomycosis, tumors of the nail
apparatus, Kawasaki disease, malignancy, beta-blocker use13,14
Endocarditis; psoriasis; renal, pulmonary, endocrine diseases; systemic skin
conditions15
for systemic nail abnormalities involves addressing the underlying etiology.
Information from references 1, and 10 through 15.
Cuticle
Nail bed
Eponychium
Nail plate
Distal
nail fold
Anterior
ligament
Nail matrix
Lateral
nail fold
Posterior
ligament
Distal edge
of nail plate
Lunula
Copyright © Thomas Jefferson University
Cuticle
ILLUSTRATION BY DAVE KLEMM
Figure 2. Dystrophic nails. This condition is
induced by repeated manipulation of the
nail plate, such as with manicures, biting, or
rubbing.
Eponychium
Figure 1. Normal nail anatomy.
affect part or all of the nail plate and can
occur in a single or multiple nails. This con­
dition is common in healthy adults and chil­
dren and is of no clinical significance.1
LONGITUDINAL MELANONYCHIA
Longitudinal melanonychia (Figure 4), also
known as vertical nail bands, are hyperpig­
mented bands that occur as normal variants
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Figure 3. Leukonychia. This condition is characterized by a white discoloration of the nail
plate from abnormal keratinization of the
underlying nail matrix.
Copyright © Thomas Jefferson University
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American Family Physician 781
Figure 4. Longitudinal melanonychia (vertical nail bands). These hyperpigmented bands
occur as normal variants in 90 percent of
black persons.18
Figure 5. Onychomycosis. The condition is
caused by a fungal, yeast, or nondermatophytic mold infection of the nail and occurs
in more than 10 percent of the population. 2
Copyright © Thomas Jefferson University
Copyright © Thomas Jefferson University
in 90 percent of black persons.18 These bands
can span the entire nail from the lunula to
the distal nail edge and may occur in mul­
tiple nails.
Vertical nail bands must be differenti­
ated from subungual melanomas, which
account for 50 percent of melanomas in per­
sons with dark skin.1 Distinguishing features
that increase the likelihood of melanoma
include a family history of melanoma, sud­
den change in the appearance of the bands,
involvement of a single nail, band width of
more than 3 mm, pigment changes extend­
ing onto the cuticle and nail fold (Hutchin­
son sign), and disruption of the nail plate.18
Vertical nail bands are uncommon in per­
sons with lighter skin.12 Any concern for
melanoma should prompt evaluation with a
punch biopsy.
Onychomycosis constitutes 50 percent
of nail conditions and occurs in more than
10 percent of the population worldwide.19
Infected nails exhibit a white-yellow discol­
oration and excessive keratinaceous buildup
underneath the nail plate. Diagnosis can be
made through potassium hydroxide testing
of scrapings. If this examination is nega­
tive for onychomycosis, a nail culture or
nail plate biopsy should be performed.17
Risk factors for this condition include older
age, tinea pedis, swimming, psoriasis, and
immunodeficiency.20
The infection associated with onychomy­
cosis is embedded within the nail, making it
difficult for medications to penetrate. Topi­
cal therapies are ineffective. Oral terbinafine
(Lamisil) has been shown to be an effective
long-term therapy against fungal infections
and has fewer side effects than some alter­
native oral agents.2 Terbinafine has also been
shown to be a safe and effective treatment in
high-risk patients, such as those with diabetes
mellitus or human immunodeficiency virus
infection.3 Oral itraconazole (Sporanox)
may be a more effective agent for onychomy­
cosis caused by yeast or nondermatophytic
molds.3,21 Oral fluconazole (Diflucan) has
also been shown to be an effective treatment
for onychomycosis infections.4 The benefi­
cial effects of oral medications may not be
apparent for 12 to 18 months. The reported
long-term recurrence rates of onychomyco­
sis range from 20 to 50 percent.22
ONYCHOMYCOSIS
Onychomycosis encompasses fungal, yeast,
and nondermatophytic mold infections of
the nail, and predominantly occurs in the
distal and lateral portion of the toenails
(Figure 5). Onychomycosis can be classi­
fied based on the location of the nail bed
involved. Distal subungual onychomycosis
is the most common form, with dermato­
phyte spread in the palmar or plantar skin.
In patients with proximal subungual ony­
chomycosis, fungal elements appear in the
deeper layers of the nail plate; this is more
common in immunocompromised patients.
White superficial onychomycosis is found in
the toenails where fungi colonize the surface
of the nail plate. Candidal onychomyco­
sis is rare and may be a sign of underlying
immunosuppression.16
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PARONYCHIA
Paronychia, which can be acute or chronic,
(Figure 6A and 6B) is an inflammatory reac­
tion caused by bacterial invasion of the folds
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of tissue surrounding the nail.7 It is char­
acterized by the rapid onset of erythema,
edema, and tenderness at the proximal and
lateral nail folds, usually following trauma.6
Most cases are caused by mixed flora. Staphylococcus aureus and Streptococcus pyogenes
are the most common aerobic bacteria asso­
ciated with paronychia, whereas anaerobic
isolates include Bacteroides, Fusobacterium
nucleatum, and gram-positive cocci.5 Non­
infectious causes of paronychia include
excessive moisture, contact irritants, and
trauma.6 Psoriasis, Reiter syndrome, and
herpetic whitlow should be part of the dif­
ferential diagnosis of recurrent cases.
Oral antibiotics may be used for severe
infections in which an abscess has not devel­
oped. Coverage for methicillin-resistant
S. aureus should be considered in highprevalence areas, and coverage for anaerobic
bacteria should be considered when exposure
to oral flora is suspected.5-7,23 If an abscess is
present, surgical drainage is indicated.6
The clinical manifestations of chronic
paronychia are similar to those of acute
paronychia; however, chronic cases last for
more than six weeks. Because of constant
infection, the cuticle may separate from
the nail plate, forming a space for invasion
of various microbes, including bacteria and
fungi.23 Patients who are immunosuppressed
or who have a systemic illness, such as diabe­
tes or human immunodeficiency virus, are at
increased risk of chronic paronychia.6,7 Treat­
ment includes avoiding exposure to contact
irritants and appropriate management of
the underlying infection. A broad-spectrum
topical antifungal, such as ketoconazole, can
be used to treat the superinfection and pre­
vent recurrence when a fungus, such as Candida albicans, is suspected.7
Paronychia associated with a pseudomonal
infection shares many of the same character­
istics of acute and chronic paronychia; how­
ever, pseudomonal paronychia commonly
leads to a green discoloration (Figure 6C).
Pseudomonal superinfection is typically
caused by repeated minor trauma to the nail
apparatus in a chronically wet environment.6,7
Persons at risk of this condition include bar­
tenders, dishwashers, and habitual nail-biters.
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A
B
C
Figure 6. Paronychia. This condition is an
inflammatory reaction caused by bacterial
invasion of the folds of tissue surrounding the
nail. (A) Acute paronychia is characterized by
the rapid onset of erythema, edema, and tenderness at the proximal nail folds. (B) Chronic
cases are similar in appearance to acute cases,
but last more than six weeks and the cuticle
may separate from the nail plate. (C) Paronychia associated with pseudomonal infection is typically caused by repeated minor
trauma in a wet environment and often
causes a green discoloration.
Copyright © Thomas Jefferson University
Therapy for pseudomonal superinfection
should include topical neomycin.
SQUAMOUS CELL CARCINOMA
Squamous cell carcinoma of the nail
(Figure 7) can present as a proliferating, ery­
thematous mass that disrupts normal nail
morphology. It is commonly mistaken for
a verrucous lesion, amelanotic melanoma,
or another chronic noninflammatory nail
process. Despite the difference in origin,
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American Family Physician 783
Figure 7. Squamous cell carcinoma of a fingernail. Because it is often mistaken for other
conditions, a biopsy is required for diagnosis.
Figure 8. Subungual hematoma. This condition is caused by bleeding in the underlying
vascular nail bed as a result of trauma.
Copyright © Thomas Jefferson University
Copyright © Thomas Jefferson University
squamous cell carcinoma (originating in the
skin) is often mistaken for onychomycosis
(originating in the nail plate). Squamous cell
carcinoma should be suspected if treatment
is ineffective, and a biopsy can confirm the
diagnosis. Treatment options include Mohs
surgery or amputation.8
SUBUNGUAL HEMATOMA
Subungual hematomas (Figure 8) are pain­
ful, dark red to black discolorations caused
by bleeding in the underlying vascular nail
bed as a result of trauma. If no nail bed
laceration is suspected, treatment consists
of drilling a hole through the nail into the
hematoma to relieve the pressure.24 This pro­
cedure involves puncturing the nail with a
hot metal wire (i.e., an electrocautery device)
or a carbon-dioxide laser. It is important
to avoid the lunula and its associated nail
matrix during this procedure.24,25
Systemic Nail Abnormalities
BEAU LINES
Beau lines (Figure 9) are horizontal grooves
on the nail plate and generally involve most
or all of the nails. They reflect an interrup­
tion of nail bed mitosis caused by severe
illness, pemphigus, high fever, or chemo­
therapy.1 Beau lines also occur in patients
with Raynaud disease. Treatment is aimed at
the underlying etiology.
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Figure 9. Beau lines. These grooves run horizontally on the nail plate and are caused by
an interruption of nail bed mitosis.
Copyright © Thomas Jefferson University
CLUBBING
Clubbing involves thickening of the nail
bed’s soft tissue, particularly in the proxi­
mal end (Figure 10A). This condition usually
affects all of the fingernails and rarely occurs
in a single digit. Clubbing can be clinically
diagnosed with an examination showing
Schamroth sign1 (Figure 10B; absence of the
diamond-shaped opening that normally
appears when the digits are opposed). Lovi­
bond angle (Figure 10C; the angle that forms
between the nail plate and the soft tissue of
the distal digit) is diagnostic of clubbing if it
is greater than 180 degrees.10
The pathogenesis of clubbing is thought
to be secondary to altered vasculature. It is
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Nail Abnormalities
theorized that the thickening of the soft
tissue develops from increased blood flow
within the microvasculature, instead of
within the larger capillaries.10 Clubbing can
be a sign of numerous underlying diseases,
such as cirrhosis, chronic obstructive pul­
monary disease, or celiac sprue.
A
KOILONYCHIA
Koilonychia (Figure 11) is a condition in
which the nail becomes increasingly concave
and therefore is often called spoon nail.1 It
commonly occurs in association with iron
deficiency anemia.10 Koilonychia can be a
normal finding in infants, disappearing
within the first few years of development.1
MEES LINES
Mees lines are transverse white lines that
may extend the complete width of the
nail plate. The lines can occur on a single
digit or multiple digits. Mees lines migrate
toward the distal end of the nail plate over
time because the abnormality is in the nail
plate and not the nail bed. The differential
diagnosis for Mees lines is narrow, and it is
thought to be caused primarily by arsenic
poisoning.1 Other heavy metal poisonings
and renal failure also may result in Mees
lines.11 The timing of the poisoning can be
estimated based on the rate of nail plate
growth.1
MUEHRCKE LINES
Muehrcke lines (Figure 12) are pairs of trans­
verse white lines caused by localized pathol­
ogy (e.g., edema from hypoalbuminemia)
within the nail bed. Because they originate in
the nail bed and not the nail plate, the lines
do not migrate distally as the nail grows. The
nail bed has abnormal vascular architecture
that can be visualized microscopically.1 The
lines disappear when pressure is applied to the
nail plate because the abnormal blood sup­
ply is compressed. If the lines are caused by
hypoalbuminemia, the nail findings improve
as the underlying condition improves.12
PINCER NAIL
Pincer nail (Figure 13) is a transverse overcur­
vature of the nail plate and may be inherited
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B
> 180 degrees
C
Figure 10. Clubbing of the nail. This condition usually affects all of the
fingernails and involves (A) thickening of the nail bed’s soft tissue,
particularly the proximal end. Diagnostic findings include (B) Schamroth sign (absence of the diamond-shaped opening that is normally
present when the digits are opposed) and (C) Lovibond angle (the
angle between the nail plate and the soft tissue of the distal digit is
greater than 180 degrees).
Copyright © Thomas Jefferson University
or acquired. The exact etiology is unknown,
but the condition has been associated with
beta-blocker use, psoriasis, onychomyco­
sis, tumors of the nail apparatus, systemic
lupus erythematosus, Kawasaki disease, and
malignancy.13 If pincer nail is associated with
medication use, the nail plate returns to nor­
mal after cessation of the medication.14 Sur­
gical treatment modalities include nail bed
cutting with or without splinting.26
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American Family Physician 785
Nail Abnormalities
A
Figure 11. Koilonychia (spoon nail). This condition is characterized by concavity of the nail
and is often associated with iron deficiency
anemia.
Copyright © Thomas Jefferson University
B
Figure 14. Splinter hemorrhages (A and B).
Distal nail bed splinter hemorrhages are commonly caused by trauma. These red-brown
longitudinal lines are a result of leaky capillaries and occur in the nail bed.
Copyright © Thomas Jefferson University
Figure 12. Muehrcke lines. Localized pathology within the nail bed leads to pairs of transverse white lines.
Copyright © Thomas Jefferson University
Figure 13. Pincer nail. This condition is characterized by the transverse overcurvature of
the nail plate.
Copyright © Thomas Jefferson University
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SPLINTER HEMORRHAGE
Splinter hemorrhages (Figure 14) are redbrown, longitudinal lines occurring in the
nail bed (not the nail plate) that develop sec­
ondary to leaky capillaries.1 When pressure
is applied to the nail, they do not disappear
because the lines are caused by blood that has
leaked out of the vasculature.10 Splinter hem­
orrhages historically have been associated
with endocarditis, typically appearing in the
midportion of the nail. However, only 15 per­
cent of patients with endocarditis have them,1
and other causes of proximal nail bed splin­
ter hemorrhages should be considered. Many
causes of the condition have been identified.
The most common cause is trauma, which
often leads to distal nail bed splinter hemor­
rhages. Systemic causes include endocarditis;
psoriasis; renal, pulmonary, and endocrine
disease; and systemic skin conditions.15
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Nail Abnormalities
The authors thank Lauren Allen and Ravi Pujara for their
assistance in the preparation of the manuscript.
Data Sources: A PubMed search was completed in
Clinical Queries using the key terms nail abnormalities,
onychomycosis, paronychia, and clubbing. The search
included meta-analyses and reviews. The Database of
Abstracts of Reviews of Effects and UpToDate were also
searched. Search dates: January through March 2011.
The Authors
and chronic paronychia. Am Fam Physician. 2008;
77(3):339-346.
8. Kuschner SH, Lane CS. Squamous cell carcinoma of the
perionychium. Bull Hosp Jt Dis. 1997;56(2):111-112.
9. Mailler EA, Adams BB. The wear and tear of 26.2: dermatological injuries reported on marathon day. Br J
Sports Med. 2004;38(4):498-501.
10.Gregoriou S, Argyriou G, Larios G, Rigopoulos D. Nail
disorders and systemic disease: what the nails tell us.
J Fam Pract. 2008;57(8):509-514.
11. Chauhan S, D’Cruz S, Singh R, Sachdev A. Mees’ lines.
Lancet. 2008;372(9647):1410.
AMBER S. TULLY, MD, is an assistant professor in the
Department of Family Medicine at the Cleveland Clinic in
Strongsville, Ohio. At the time this article was written, she
was an assistant professor in the Department of Family
and Community Medicine at Thomas Jefferson University
Hospital in Philadelphia, Pa.
13.Tosti A, Iorizzo M, Piraccini BM, Starace M. The nail in
systemic diseases. Dermatol Clin. 2006;24(3):341-347.
KATHRYN P. TRAYES, MD, is an assistant professor in
the Department of Family and Community Medicine at
Thomas Jefferson University Hospital, and is assistant
dean of student affairs and career counseling at Jefferson
Medical College.
15.Saladi RN, Persaud AN, Rudikoff D, Cohen SR. Idiopathic splinter hemorrhages. J Am Acad Dermatol.
2004;50(2):289-292.
JAMES S. STUDDIFORD, MD, is a professor in the Department of Family and Community Medicine at Thomas Jefferson University Hospital.
Address correspondence to Amber S. Tully, MD, 16761
South Park Center/ST10, Strongsville, OH 44136 (e-mail:
[email protected]). Reprints are not available from the
authors.
Author disclosure: No relevant financial affiliations to
disclose.
12.Zaiac MN, Daniel CR III. Nails in systemic disease. Dermatol Ther. 2002;15(2):99-106.
14.Bostanci S, Ekmekci P, Akyol A, Peksari Y, Gürgey E.
Pincer nail deformity: inherited and caused by a betablocker. Int J Dermatol. 2004;43(4):316-318.
16. Diseases of hair and nails. In: Cecil RL, Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa.: Elsevier/Saunders; 2012.
17. Lawry MA, Haneke E, Strobeck K, Martin S, Zimmer B,
Romano PS. Methods for diagnosing onychomycosis:
a comparative study and review of the literature. Arch
Dermatol. 2000;136(9):1112-1116.
18.Levit EK, Kagen MH, Scher RK, Grossman M, Altman E.
The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol. 2000;42(2 pt 1):269-274.
19.Allevato MA. Diseases mimicking onychomycosis. Clin
Dermatol. 2010;28(2):164-177.
20.Sigurgeirsson B, Steingrímsson O. Risk factors associated with onychomycosis. J Eur Acad Dermatol Venereol. 2004;18(1):48-51.
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4.Gupta AK, Ryder JE, Johnson AM. Cumulative metaanalysis of systemic antifungal agents for the treatment
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24.Helms A, Brodell RT. Surgical pearl: prompt treatment
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25.Palamarchuk HJ, Kerzner M. An improved approach to
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6.Rockwell PG. Acute and chronic paronychia. Am Fam
Physician. 2001;63(6):1113-1116.
7. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute
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Volume 85, Number 8
26.Ghaffarpour G, Tabaie SM, Ghaffarpour G. A new
surgical technique for the correction of pincer-nail
deformity: combination of splint and nail bed cutting.
Dermatol Surg. 2010;36(12):2037-2041.
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American Family Physician 787